Tuesday, 6 June 2017

Causes of school refusal in children

  • Physical illness (most common) 

  • Anxiety and depression 

  • Deliberately kept home by parents 

  • Truancy

  • Miserable conditions at school e.g. Bullying 

Summary of Treatment Guidelines for ADHD

Summary of Treatment Guidelines  for ADHD



AAP Treatment Recommendations Nov 2019  



Second line  

Preschool children (4-5 years)  

Behaviour therapy  



Methylphenidate, if no significant improvement and moderate-to-severe functional impairment  

Elementary school (6–11 years)  

Behaviour therapy or medication, preferably both.   


stimulants > atomoxetine > guanfacine ER > Clonidine ER  

Summary, NICE Treatment Recommendations 2018  



Second line  

Children under 5 years  


Group parent-training program  



(Only a specialist can start)  

Start medications only after seeking advice from ADHD specialist services  

Children over 5 years  

Discussion and ADHD-focused Support   



Offer a minimum of 1 or 2 sessions of support, can be  



education on the causes and impact of ADHD  

advice on parenting strategies liaison with school, parents, and carers  


 Before starting treatment, discuss with the carers  

The benefits of a healthy lifestyle, including exercise The benefits and harms of non-pharmacological and pharmacological treatments Their preferences and concerns How other conditions affect treatment choices  

Importance of treatment  


Record the person's preferences and concerns   

Ask if they wish a carer to join discussions  

Reassure that they can revisit decisions  


      Children over 5  


Lisdexamfetamine, after 6weeks trial off the methylphenidate   


Correspondence justpsychiatry@outlook.com  

A 9-year-old child presented to you in the outpatient department, brought by his mother who was concerned because of his poor performance at school, saying his brother and sister are much more competent. On enquiry, she revealed that the child seems absent-minded, repeatedly loses items, does not seem to listen when being talked to, is fidgety and keeps running and bouncing ‘as if driven by a motor.’ His academic report revealed ‘below-average performance’ and he scored of 90 Weschler intelligence scale for children. The rest of the assessment was unremarkable.   

What would be your recommendation?   

  1. Atomoxetine  

  1. Clonidine  

  1. Methylphenidate  

  1. Lisdexamfetamine  

  1. Psychosocial Interventions   


The scenario best depicts a mild case of attention deficit hyperactivity disorder (ADHD).  

Most patients will need psychosocial interventions and medications combined. However, the National Institute of Clinical Excellence recommends psychosocial interventions as the first choice of therapy. American Academy of paediatrics recommends psychosocial interventions as a primary treatment strategy for preschool children (4-5 years of age) and combined psychosocial and pharmacological treatments for older children. Both NICE and AAP recommend methylphenidate as the preferred medication if you must start one. Similarly, Canadian guidelines for the management of ADHD recommend psychosocial interventions before a trial of medication. They recommend methylphenidate and lisdexamfetamine as first-line medication. Nonetheless, patient individualization is important. For instance, if a patient has a comorbid tic disorder, clonidine will treat both the tic disorder and symptoms of ADHD, while stimulants may worsen the tics. Likewise, a patient with comorbid conduct disorder will need other specific interventions.   

The best answer would be psychosocial interventions. Please let us know your thoughts. We have summarized the Recommendations of AAP and NICE on the next page.  


  1. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practise guidelines (CAP-guidelines) [Internet]. 3rd. Toronto: CADDRA; 2011.  

  1. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Paediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654  

  1. Overview | Attention deficit hyperactivity disorder: diagnosis and management | Guidance | NICE. (2018). Retrieved from https://www.nice.org.uk/guidance/ng87    


Correspondence justpsychiatry@outlook.com  

Which one of these disorders can not coexist with Hyperactivity disorder (according to ICD classification)?
  1. Anxiety disorder
  2. Depression 
  3. Autism
  4. Conduct disorder

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